The U.S. healthcare market projects that by 2022 90 million Americans will be in an ACO. The upward trend in population health management (PHM) makes the move towards risk-based contracts increasingly urgent for health systems. The industry has been largely unprepared for the shift, as it hasn’t established a clear definition of population health or solid guidelines on transitioning from volume to value. Organizations can, however, prepare for the demands of PHM by adopting a solution that manages comprehensive population health data, provides advanced analytics from new and complex challenges, and connects them with the deep expertise to thrive in a value-based landscape.
Population Health and Care Management
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To succeed in improving outcomes and lowering costs, care management leaders must begin by selecting the patients most likely to benefit from their programs. To identify the right high-risk and rising-risk patients, care managers need data from across the continuum of care and tools to help them access that knowledge when they need it. Analytics-driven technology helps care managers identify patients for their programs and manage their care to improve outcomes and lower costs in six key ways:
- Identifies rising-risk patients.
- Uses a specific social determinant assessment to capture factors beyond claims data.
- Integrates EMR data to achieve quality measures.
- Identifies patients for palliative or hospice care.
- Identifies patients with chronic conditions.
- Increases patient engagement.
Population health management (PHM) strategies help organizations achieve sustainable outcomes improvement by guiding transformation across the continuum of care, versus focusing improvement resources on limited populations and acute care. Because population health comprises the complete picture of individual and population health (health behaviors, clinical care social and economic factors, and the physical environment), health systems can use PHM strategies to ensure that improvement initiatives comprehensively impact healthcare delivery. Organizations can leverage four PHM strategies to achieve sustainable improvement:
- Data transformation
- Analytic transformation
- Payment transformation
- Care transformation
To earn legitimacy and resources within a healthcare organization, care management programs need objective, data-driven ways to demonstrate their success. The value of care management isn’t always obvious; while these programs may, in fact, be responsible for improvements in critical metrics, such as reducing readmissions, C-suite leaders need visibility into care management’s impact and processes to understand precisely how they’re improving care and lowering costs at their organizations. Five analytics-driven technologies give healthcare leaders a comprehensive understanding of care management performance:
- The Patient Stratification Application
- The Patient Intake Tool
- The Care Coordination Application
- The Care Companion Application
- The Care Team Insights Tool
Data plays a big role toward empowering patients to become more involved in their care. With data, digital tools, and education, patient empowerment can act like a blockbuster drug to produce exceptional outcomes. Data empowers patients five ways:
- Promotes patient engagement.
- Produces patient-centered outcomes.
- Helps patients practice self-care.
- Improves communication with clinicians.
- Leads to faster healing and independence.
Care management programs are most successful when patients are deeply engaged in their own care. Using the motivational interviewing technique, care managers work with patients to identify personal care goals and motivators to follow the care management program. Ten strategies guide the motivational interviewing process, each focusing on patient-centered insights (e.g., pros and cons to following care management and barriers to adherence). With mobile technology to support these interactions, motivational interviewing can become a seamless, and vital, part of the care management workflow.
Care management is a tool for population health that focuses scarce healthcare resources on the sickest patients. Care management leaders need to know who those sickest patients are (or may be). The static risk models typically used for stratifying patients into risk categories only paint a partial picture of health and are ineffective for modern care management programs. Custom algorithms are now capable of predicting risk based on multiple risk models and multiple data sources. They help care management teams confidently stratify patient populations to paint a complete picture of care needs and efficiently deliver care to those who need it most. This article explains how custom algorithms work on static risk models to normalize risk scores and improve patient stratification, care management, and, ultimately, population health management.
With an estimated 80 percent of medical errors resulting from miscommunication among healthcare teams, organizations can significantly improve outcomes with better communication. A communication methodology outlines the essential information clinicians need to share, giving care teams the knowledge they need, when they need it, to make informed treatment decisions. One communication toolkit, SBAR (Situation, Background, Assessment, Recommendation), defines the essential information clinicians must share when they hand off patient care from the inpatient to the ambulatory setting:
- S (situation): The patient’s current situation.
- B (background): Information about the current situation.
- A (assessment): Assessment of the situation and background and potential treatment options.
- R (recommendation): Recommended action.
Effective care management is essential during the first 30 days after discharge to prevent unnecessary readmission and associated costs. Care managers can follow a 10-step readmission reduction program to help patients stay on track with recovery and avoid acute care:
- Call the patient within two days of discharge.
- Assess the patient’s self-care capacity.
- Frontload homecare and ensure patient 'touches', if appropriate.
- Conduct a home safety evaluation.
- Order and install durable medical equipment prior to discharge.
- Order an emergency alert/medication reminder system and preprogram important phone numbers on patient’s phone.
- Implement fall prevention program, intervention, and education.
- Provide in-home education on new diagnoses or unmanaged chronic conditions.
- Connect the patient with community resources.
- Establish a best practice for follow-up phone calls after discharge.
Influential healthcare financial trends in 2017 emerged in three areas:
- Transitions in payment.
- Disruption from familiar players and newcomers.
- Emerging data skillsets.
Reducing readmissions is an important metric for health systems, representing both quality of care across the continuum and cost management. Under the Affordable Care Act, organizations can be penalized for unreasonably high readmission rates, making initiatives to avoid re-hospitalization a quality and cost imperative. A transitional care management plan can help organizations avoid preventable readmissions by improving care through all levels in five steps:
- Start discharge at the time of admission.
- Ensure medication education, access, reconciliation, and adherence.
- Arrange follow-up appointments.
- Arrange home healthcare.
- Have patients teach back the transitional care plan.
8 in 10 Hospitals Stand Pat on Population Health Strategy, Despite Uncertainty Over the Affordable Care Act’s Future
A 2017 survey by Health Catalyst shows that despite uncertainty about the future of the Affordable Care Act, 80 percent of healthcare executives have not paused or otherwise changed their population health management strategy. 68 percent said that PHM is “very important” to their healthcare delivery strategy, while fewer than 3 percent said it was not important at all. The results show that executives view the move to value-based care as inevitable, and they view a PHM strategy as an integral part of their future efforts.
The documentary, “A Coalition of the Willing: Data-Driven Population Health and Complex Care Innovation in Low-Income Communities” shows how precision medicine and care management can be effective tools for successful population health. The film highlights three programs that use data to hotspot populations of high-risk, high-need patients, and then deploy unique, targeted care management inventions. The documentary, which initially aired during the 2017 Healthcare Analytics Summit, presents hopeful solutions, scalable across diverse patient populations, that are leading to exceptional results and the future of healthcare transformation.
Joe’s story isn’t a unique one in the U.S. Having been admitted to the hospital five times in one month, Joe isn’t taking his medications and doesn’t exercise. In short, he struggles to follow his care plan. The Care Management Show, an entertaining, interactive theatrical performance, demonstrates why health systems need to adopt innovative, data-driven approaches to care management that prevent patients from falling through the cracks by integrating all aspects of patient care:
- Data integration.
- Patient stratification and intake.
- Care coordination.
- Patient engagement.
- Performance measurement.
Population health management (PHM) is in its early stages of maturity, suffering from inconsistent definitions and understanding, overhyped by vendors and ill-defined by the industry. Healthcare IT vendors are labeling themselves with this new and popular term, quite often simply re-branding their old-school, fee-for-service, and encounter-based analytic solutions. Even the analysts —KLAS, Chilmark, IDC, and others—are also having a difficult time classifying the market. In this paper, I identify and define 12 criteria that any health system will want to consider in evaluating population health management companies. The reality of the market is that there is no single vendor that can provide a complete PHM solution today. However there are a group of vendors that provide a subset of capabilities that are certainly useful for the next three years. In this paper, I discuss the criteria and try my best to share an unbiased evaluation of sample of the PHM companies in this space.
Care management programs play a large part in many health systems’ population health strategies. However, these programs can consume a lot of resources. It is important to know if a care program is effective, and eventually, to show a positive ROI. Many roadblocks stand in the way:
- Complexity of Environment
- Prolonged Time to ROI
- Lack of Access to Disparate Data
- Difficulty Engaging the Patient
In today’s data-rich healthcare environment, patient registries put knowledge in front of the people who will use it to improve outcomes and population health. Non-IT professionals (e.g., clinicians and researchers) often don’t have direct, timely access to operational and clinical data. As a result, organizations miss out on important improvement opportunities and data-driven point-of-care decisions. Knowledge too often remains siloed in the enterprise data warehouse (EDW) or among specialized groups. Patient registries remove these barriers. It allows clinicians and researchers to make informed choices and frees up data analysts to focus on their priority areas.